Center for Improvement in Healthcare Quality Newsletter
February 2022

ARS Regulatory Alerts

CIHQ-ARS notifies member organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Each alert summarizes the standard / regulation, likely impact to members, and recommends compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.

New Regulatory Alert

Alert Date
January 14, 2022
Alert Subject
Supreme Court Upholds Vaccine Mandate for Healthcare Workers
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other: Supreme Court
Alert Background
In a ruling issued on Thursday, January 13, 2022 the Supreme Court upheld the Biden administration’s mandate for healthcare workers employed in facilities that receive Medicare funding to be fully vaccinated against the COVID-19 virus. The ruling overturns a lower-court injunction filed by multiple States.
This means that the vaccine mandate will now apply nation-wide. In late December of 2021 CMS indicated that enforcement of the mandate would not apply to the following States: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.
With this Supreme Court ruling, the vaccine mandate will now apply to all 50 States and territories. It is anticipated that CMS will move quickly to revise its December guidance to State Agency’s and Accrediting Organizations to begin enforcing the mandate on January 27, 2022.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
January 14, 2022
Alert Subject
HHS Extends COVID-19 Public Health Emergency Declaration
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other: HHS
Alert Background
In a declaration dated January 14, 2022. Secretary of Health and Human Services Xavier Becerra extended the public health emergency due to the COVID-19 virus. The extension goes into effect on January 16, 2022.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
January 18, 2022
Alert Subject
Texas Remains Exempt from COVID Vaccine Mandate
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a letter to State enforcement agencies and accrediting organizations dated 1/14/22, CMS indicated that the COVID vaccine mandate does not yet apply to Texas. Both State and accreditation surveyors have been instructed not to enforce the vaccine mandate until further notice.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
January 21, 2022
Alert Subject
CMS to Enforce COVID Vaccine Mandate in Texas
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a letter to State enforcement agencies and accrediting organizations dated 1/20/22, CMS indicated that the COVID vaccine mandate will now apply to Texas. Both State and accreditation surveyors have been instructed begin enforcement the vaccine mandate effective February 19, 2022.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
January 25, 2022
Alert Subject
CMS Announces Vaccine Requirements for Surveyors
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a letter to State enforcement agencies (SA’) dated 1/25/22, CMS provided national guidance on vaccine requirements for surveyors who perform on-site surveys in Medicare participating facilities.
In the guidance, CMS expanded on the exclusionary criteria for all surveyors (including CLIA and Life Safety Code surveyors) entering facilities to include vaccination status. Surveyors who are not fully vaccinated (unless vaccination is medically contraindicated or the individual is legally entitled to a reasonable accommodation under federal civil rights laws because they have a disability or sincerely held religious beliefs, practices, or observances that conflict with the vaccination requirement) should not participate as part of the onsite survey team performing federal oversight of certified providers and suppliers (including accreditation surveys performed under an AO’s deeming authority).
CMS went on state that “The State Survey Agencies and AOs are ultimately responsible for compliance with this expectation. Therefore, certified providers and suppliers are not permitted to ask surveyors for proof of their vaccination status as a precondition for entry.”
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.